Emergency Medical Information Form - LIFE Senior Services

Emergency Medical Information Form

Name ________________________________________ Address ______________________________________

City _________________________ State_____ Zip Code_______________ Home phone_____________________

Work phone___________________ Cell phone ___________________ Email _____________________________

Date of Birth__________________ SSN:________________________ (keep this information secure) Blood Type _______

Prior transfusion reaction (describe)__________________________________________________________________

Please check all that apply: Contact lenses _____ Dentures _____ Diabetic_____ Epileptic_____ Metal in body_____

Additional information: _________________________________________________________________________

Allergies to medications?_____ Please list ___________________________________________________________

List all medical conditions:_______________________________________________________________________

_________________________________________________________________________________________

List Dietary Restrictions:_________________________________________________________________________

List all surgeries and hospitalizations:

Year

Surgery Performed/Reason for Hospitalization

Location

Medicare Beneficiary? Yes ___ No ___ Medicare Part D? Yes ___ No ___ Medicare # __________________________ Supplementary/Insurance Company ____________________________________ Phone ______________________ Group #___________________________ Policy #___________________________ Attach Copy of Cards Preferred Hospital: __________________________________________________________________ Primary physician and/or medical treatment facility: Physician Name __________________________________ Phone _____________________________

Additional physicians/specialists: Physician Name ____________________________ Phone ____________________ Specialty: __________________

Physician Name ____________________________ Phone ____________________ Specialty: __________________

Physician Name ____________________________ Phone ____________________ Specialty: __________________

Case Manager or Social Worker Information: Name ___________________________ Agency ________________________ Agency Phone # ____________

Next of kin or person to be notified in an emergency: Name _______________________________ Relationship __________________ Phone _____________________

Email ___________________________________________________

Name _______________________________ Relationship __________________ Phone _____________________

Email ___________________________________________________

Name _______________________________ Relationship __________________ Phone _____________________

Email ___________________________________________________

Legal documents: Attach a copy and instructions on where to access originals Is there a Power of Attorney? Yes ___ No ___ Is there an Oklahoma Advanced Directive (Living Will) Yes ___ No ___ Is there a Do Not Resuscitate order? Yes ___ No ___ Health Care Proxy/Power of Attorney Contact Info:

Name _____________________________ Relationship __________________ Phone ________________________

Email ___________________________________________________

Pharmacy phone __________________________ Medication List Include over-the-counter, vitamins and prescription medications

Rx Name

Dose

When to take

Reason for taking

Prescribing M.D.

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